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Home , Allergic rhinitis, Decongestant, Lodoxamide, Mast cell stabilizer, Phlegm, Rhinitis

Guidelines for Clinical Care Quality Department Ambulatory

Allergic Guideline Team Team Leader Patient population: Adults and pediatrics David A DeGuzman, MD General Medicine Objectives: Assist in the diagnosis and cost-effective treatment of allergic rhinitis. Team Members Catherine M Bettcher, MD Key Aspects & Recommendations: Family Medicine Diagnosis. Allergic rhinitis is an antigen-mediated of the that may extend

R Van Harrison, PhD into the . Diagnosis is usually made by history and examination (“itchy, runny Medical Education sneezy, stuffy”). A symptom diary and a trial of may be helpful to confirm a diagnosis. testing is not commonly needed to make the diagnosis, but may be helpful for patients with Christine L Holland, MD multiple potential sensitivities Allergy Therapy. The goal of therapy is to relieve symptoms. Lauren M Reed, MD 1. Avoidance of is the first step [I A*]. (See text for details). If avoidance fails: Pediatrics 2. An over-the-counter (OTC), non-sedating ( [Claritin], ([Zyrtec], Tami L Remington, PharmD [Allegra]) should be tried initially. They provide relief in most cases. They prevent Pharmacy and relieve nasal itching, sneezing, and , and ocular symptoms, but tend to be less

Mark A Zacharek, MD effective for [I A*]. If symptoms persist consider the following options: Otolaryngology 3. Other : • Intranasal (prescription and OTC) are the most potent medications available for

[I A*] Initial Release treating allergic rhinitis . They control itching, sneezing, rhinorrhea, and stuffiness in most July, 2002 patients, and may help ocular symptoms. They have a relatively good long-term safety profile. Most Recent Major Update Generic intranasal corticosteroids for adults and children are: (Flonase), now October, 2013 available OTC, acetonide (Nasalcort AQ), and (Nasarel). • Oral (OTC) decrease swelling of the nasal mucosa which, in turn, alleviates

Ambulatory Clinical nasal congestion [I A*]. They can be combined with oral or other agents. Guidelines Oversight However, they are associated with appreciable side effects, especially in geriatric patients, and Grant Greenberg, MD, MA, should only be considered when congestion is not controlled by other agents. They are MHSA contraindicated with monoamine oxidase inhibitors (MAOIs), in uncontrolled , R. Van Harrison, PhD and in severe coronary artery and benign prostatic hyperplasia (BPH). • inhibitors (prescription-only) are less effective than intranasal corticosteroids [II

Literature search service A*]. Consider using for patients who cannot tolerate first line agents or have co-morbid Taubman Medical Library . • Intranasal cromolyn (OTC) is less effective than intranasal corticosteroids [II A*]. Cromolyn is a good alternative for patients who are not candidates for corticosteroids. It is most effective For more information: 734-936-9771 when used regularly prior to the onset of allergic symptoms. • Intranasal antihistamines (), while effective in treating the nasal symptoms associated with seasonal and perennial rhinitis and nonallergic vasomotor rhinitis, offer no therapeutic © Regents of the benefit over conventional treatment and incur additional cost [II A*]. University of Michigan • Ocular preparations should be considered for patients with allergic who are not adequately controlled with or cannot tolerate an oral antihistamine or high dose nasal , These guidelines should not be which do provide some improvement in ocular symptoms [II A*]. construed as including all proper methods of care or excluding Referral. Appropriate criteria for referral may include identification of specific allergens through testing, other acceptable methods of care intolerance to or failure of medical therapy, severe reactions, associated comorbid conditions, or desire for reasonably directed to obtaining the same results. The ultimate [I D*]. judgment regarding any specific clinical procedure or treatment Controversial Issues must be made by the physician in Medication vs. immunotherapy. A formal cost-benefit analysis of medication therapy versus light of the circumstances presented by the patient. immunotherapy (allergy shots) has not been performed; however, patients with moderate to severe symptoms that continue year round (seasonal or perennial allergic rhinitis) may benefit most from

immunotherapy [II D*]. can be cost effective in children with asthma.

Special Considerations. Certain patient groups (pediatrics, geriatrics, and severe asthmatics) may pose diagnostic and therapeutic challenges. * Strength of recommendation: I = generally should be performed; II = may be reasonable to perform; III = generally should not be performed. Level of evidence supporting a diagnostic method or an intervention: A=randomized controlled trials; B=controlled trials, no randomization; C=observational trials; D=opinion of expert panel.

Figure 1. Treatment of Allergic Rhinitis

Presumptive clinical diagnosis of allergic rhinitis? (Table 1)

Discuss treatment options with patient (Tables 3 & 4). Yes Refer to specialist Referral indicated? (Table 5)

No

Initiate Treatment: 1) avoidance education 2) trial of medication (Table 6) 3) combination therapy Consider alternative diagnoses (Table 2) & evaluate as indicated. Consider: • Satisfactory response? No limited sinus CT scan • other diagnostic tests • treatment trial with alternative medication Yes • referral

Follow up periodically. Discuss complications and potential long- term side effects (Tables 7 & 8).

Table 1. Complications of Allergic Rhinitis

General Concerns / Complications Adults Children Progression to and exacerbation of asthma X X Deviations in facial growth X Hyposmia X X Incisor protrusion X Malocclusion (crossbite, high palatal arch) X Nasal polyps X ? Middle ear effusion: hearing loss X X X X Sleep disorders X X

X = Possible; ? = Uncertain

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Table 2. Symptoms and Signs Suggestive of Allergic Rhinitis

Symptoms Seasonal, perennial or episodic (associated with exposure, e.g., cat) itching of eyes, ears, nose, palate; sneezing, nasal congestion, chronic sniffling, clear rhinorrhea, post nasal drip, pressure of nose or over paranasal sinus, morning . Red, watery eyes or ropy discharge. Family or personal history , asthma, . Physical findings Ocular-allergic shiners, Dennie’s lines, scleral injection with corkscrewing of vessels, conjunctival with possible cobblestoning. Nasal-transverse nasal crease (salute), congestion, pale pink or bluish mucosa, clear or thick mucoid discharge, structural issues such as deviated septum, turbinate hypertrophy, presence of nasal polyps, pharyngeal cobblestoning.

Table 3. Alternative Diagnoses with Typical Characteristics

Alternative Diagnosis Typical Characteristics

Acute rhinosinusitis Facial pressure or pain, purulent nasal discharge; maxillary toothache; failure to respond to decongestants; or cough may be present; typically follows an allergy flare-up or a viral URI Chronic rhinosinusitis Facial pressure or pain, purulent discharge; fever often absent; may be present in addition to allergic rhinitis; symptoms may wax and wane over time; chronic hyposmia. Viral URI Self-limited course with symptoms (clear rhinorrhea, cough, ache, low grade fever) usually resolving within 3-7 days Structural abnormalities Include nasal septal deviation, nasal polyps, enlarged turbinates, adenoidal hypertrophy. Obstruction may be unilateral or bilateral and may or may not be seen on routine nasal examination. Gustatory rhinitis Clear rhinorrhea caused by hot (i.e. soup) or spicy foods, may have prominent nasal congestion as a symptom. Also called “rebound rhinitis;” caused by overuse of topical decongestants; diagnosis is easily made by history; may mask another underlying condition such as septal deviation or allergic rhinitis. Autonomic dysfunction Clear rhinorrhea, nasal obstruction, often depends on position (e.g., supine), may be episodic. (vasomotor rhinitis ) may exacerbate symptoms. Common in geriatric patients Medication Common medications causing rhinitis symptoms include calcium channel blockers, beta blockers, ACE inhibitors and alpha blockers Atrophic rhinitis Also called “ozena”, caused by over-resection of nasal turbinate tissue or poor production, resulting in nasal dryness and crusting. Foul odor may be present. Gastroesophageal reflux Under-recognized cause of post-nasal drip, cough, and globus sensation; hoarseness or frequent throat clearing may also be present Non-allergic rhinitis Post-nasal drip sensation often with morning

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Table 4. Advantages & Disadvantages of Treatment Options

Treatment Options Advantages Disadvantages

Environmental • Beneficial with minimal ongoing cost (may • Difficult to assess with certainty whether exposure Control / Avoidance be an initial cost to modify environment) has been controlled of Allergens • Effectiveness of chemical barriers requires repeated application? • Effective eradication requires repeated treatment Medications • Patient preference • Cost of medication • Rapid onset • Medication side effects (e.g., sedation, impaired (See also: • May control non-allergic rhinitis symptoms performance, local and epistaxis from Tables 7 & 8) • Many choices (See Tables 7 & 8) topical agents, nasal septal perforation with nasal steroids [rare])

Allergy Testing, Skin • Beneficial in defining allergens in complex • Cost of treatment Testing (preferred) patients or to institute immunotherapy • Patient discomfort or RAST Testing • May help direct avoidance therapy • Must temporarily stop oral antihistamines

Subcutaneous • Only disease remitting therapy available • Benefits of therapy not seen until several months Immunotherapy • Medication requirements usually reduced of treatment • Benefits may persist after therapy stopped • Requires patient commitment • May be less costly in long term • (rare) • May prevent polysensitization and onset of asthma in children

Table 5. Order of Medication Addition Based on Presenting Symptoms

Addition Nasal Obstructive Rhinorrhea without Comorbid Persistent Asthma Sequence Symptoms Obstruction First Intranasal Antihistamine Intranasal corticosteroid Second Antihistamine +/- Intranasal corticosteroid Leukotriene inhibitors OR antihistamine +/- decongestant Third Leukotriene inhibitors Leukotriene inhibitors If intranasal corticosteroid use above, ADD antihistamine +/- decongestant If antihistamine +/- decongestant, ADD intranasal corticosteroid Fourth Intranasal antihistamine Intranasal antihistamine Intranasal antihistamine Fifth Intranasal stabilizer Intranasal Intranasal mast cell stabilizer Sixth Intranasal Intranasal anticholinergics Intranasal anticholinergics

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Table 6. Pharmacologic Therapy for Allergic Rhinitis in Children and Adolescents, Age 6 months-17 years

Avail- 30-day Generic Name Brand Name Initial Dose ability Generic Brand Intranasal Corticosteroids Flonase ≥ 4 yrs: 1–2 sprays EN 1x/day OTC n/a $16 spray flunisolide 6 to 14 yrs: 2 sprays EN 2x/day Nasarel Rx $32 $66 spray ≥ 15 yrs: 2-4 sprays EN 2x/day 2-12 yrs: 1 spray EN 1x/day spray Nasacort AQ Rx $40 $123 ≥ 12 yrs: 2 sprays EN 1x/day aerosol spray Veramyst ≥ 4 yrs: 1–2 sprays EN 1x/day Rx n/a $120 spray beclomethasone dipropionate Qnasl > 12 yrs: 2 sprays EN 1x/day Rx n/a $126 aerosol spray 2 to 11 yrs: 1 spray EN 1x/day Nasonex AQ Rx n/a $133 spray ≥ 12 yrs: 2 sprays EN 1x/day Rhinocort Aqua ≥ 6 yrs: 1 spray EN 1x/day Rx n/a $137 spray beclomethasone dipropionate Beconase AQ ≥ 6 yrs: 1–2 sprays EN 2x/day Rx n/a $176 spray Oral Antihistamines – 2nd Generation, with and without decongestant loratadine tablet 10 mg 2-5 yrs: 5 mg once daily solution 5mg/5ml Claritin ≥ 6 yrs: 10 mg once daily OTC $2 $21 disintegrating tab 10 mg chewable tabs 5 mg cetirizine syrup 5mg/5ml 2 to 5 yrs: 2.5 or 5 mg once daily chewable tab 5,10 mg Zyrtec ≥ 6 yrs: 10 mg once daily or OTC $4 $20 disintegrating tab 10 mg divided BID tablet 10 mg fexofenadine and ≥ 12 yrs: 60 mg/120 mg every 12 hr $16 $20 extended rel tab 60 mg-120 mg Allegra D-12 ≥ OTC 12 yrs: 180 mg/240 mg every $13 $50 extended rel tab 180 mg-240 mg Allegra D-24 24 hr loratadine and pseudoephedrine Claritin D-12 ≥12 yrs:5 mg/120 mg every 12 hrs $13-25 $22 extended rel tab 5 mg-120 mg Claritin D-24 ≥12 yrs: 10 mg/240 mg every 24 OTC $45 n/a extended rel tab 10 mg-240 mg hrs 6 months to 5 yrs: 1.25 mg once solution 2.5 mg/5ml daily in evening tablet 5 mg 6 to 11 yrs: 2.5 mg once daily in Xyzal Rx $22 $92 evening ≥ 12 yrs: 5 mg once daily in the evening ≥ 12 yrs: 5 mg/120 mg every 12 cetirizine and pseudoephedrine Zyrtec D-12 OTC $25 $25 extended rel tab 5 mg-120 mg hr fexofenadine 6 to 11 yrs: 30 mg 2x/day suspension 30 mg/5 ml Allegra ≥ OTC $33 $77 disintegrating tab 30 mg 12 yrs: 60 mg 2x/day or 180 mg tablet 60, 180 mg 1x/day 6 to 11 months: 1 mg once daily syrup 0.5 mg/ml 1-5 yrs: 1.25 mg once daily Clarinex Rx $50 $136 disintegrating tab 2.5, 5 mg 6-11 yrs: 2.5 mg once daily tablet 5 mg ≥ 12 yrs: 5 mg once daily * Pricing information for brand products based on average wholesale price (AWP) – 10% found in the RedBook 1/2013 catalog. Pricing information for generic products is based on the Blue Cross Blue Shield Maximum Allowable Cost (MAC) price + $3 as posted on 1/2013. Pricing for OTC products is based on http://www.drugstore.com/ EN=each nostril

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Table 6. Pharmacologic Therapy for Allergic Rhinitis in Children & Adolescents, Age 6 months-17 years, cont’d

Avail- 30-day Generic Name Brand Name Initial Dose ability Generic Brand Oral Antihistamines – 2nd Generation, with and without decongestant, continued desloratadine and pseudoephedrine ≥ 12 yrs: 2.5 mg/120 mg every extended rel tab 2.5 mg-120 mg Clarinex D-12 12 hrs Rx n/a $112 extended rel tab 5 mg-240 mg Clarinex D-24 ≥ 12 yrs: 5 mg/240 mg every 24hrs n/a $170 Oral Antihistamines (1st Generation) (For use only in special circumstances as described) a Tavist Allergy 6 to 12 yrs: 0.67-1.34 mg BID $5 $22 syrup 0.5 mg/5 ml (Rx) syrup Rx, $40 $150 tablet 1.34 (OTC), ≥ 13 yrs: 1.34 mg BID OTC $14 $65 tablet 2.68 mg (Rx) chlorpheniraminea 2 to 5 yrs: 1 mg every 4-6 hr Chlor- solution 2 mg/5 ml 6 to 12 yrs: 2 mg every 4-6 hr Trimeton, OTC $10 $15 tablet 4 mg > 12 yrs: 4 mg every 4-6 hr or 12 others mg ER every 12 hrs diphenhydraminea 2 to 5 yrs: 15 mg every 6 hrs solution 12.5 mg/5 ml 6 to 12 yrs: 30 mg every 6 hrs , tablet 25 mg ≥ OTC $10 $15 others 12 yrs: 25 mg every 6 hrs, SR 120 mg every 12 hrs or 240 mg once daily Oral decongestants pseudoephedrine Sudafed, 2 to 5 yrs: 15 mg IR every 4-6 liquid 30 mg/5 ml, 7.5 mg/0.8 ml others hrs, max 60 mg/day solution 15 mg/5 ml 6 to 12 yrs: 30 mg IR every 4-6 hrs, max 120 mg/day tablets 30, 120, 60 mg OTC $13 $20 ≥ 12 yrs: 60 mg IR every 4-6 hrs, max 240 mg/day or 120 mg SR every 12 hrs or 240 mg SR every 24 hrs Leukotriene Inhibitors sodium Singulair 6 months to 5 yrs: 4 mg daily $24 chewtab 4, 5 mg 6 to 14 yrs: 5 mg daily Rx $200 $170 all granule pckt 4 mg ≥ 15 yrs: 10 mg daily $22 tablet 10 mg Intranasal Antihistamine azelastine hydrochloride Astelin, 5 to 11 yrs: 1 spray EN 2x/day $145 Rx $95 spray Astepro ≥ 12 yrs: 1-2 sprays EN 2x/day $132 hydrochloride Patanase 6 to 11 yrs: 1 spray EN 2x/day Rx n/a $167 spray ≥ 12 yrs: 2 sprays EN 2x/day Intranasal Mast Cell Stabilizers cromolyn sodium Nasalcrom ≥ 2 yrs: 1 spray EN 3-6 x/day OTC $15 $30 spray Intranasal Atrovent ≥ 6 yrs: 0.03% solution, 2 sprays spray 0.03% EN 2-3x/day Atrovent 5-11 yrs: 0.06% solution, 2 sprays $6 $17 Rx 0.06% EN 3x/day for up to 4 days $11 $30 ≥ 12 yrs: 0.06% solution, 2 sprays EN 3-4x/day for up to 4 days Ocular Antihistamines fumarate Zaditor, Alaway, ≥ 3 yrs: 1 drop affected eye(s) 2- solution Claritin Eye, 3x/day OTC $11 $13-15 Zyrtec Itchy Eye * Pricing information for brand products based on average wholesale price (AWP) – 10% found in the RedBook 1/2013 catalog. Pricing information for generic products is based on the Blue Cross Blue Shield Maximum Allowable Cost (MAC) price + $3 as posted on 1/2013. Pricing for OTC products is based on http://www.drugstore.com/ EN=each nostril

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Table 6. Pharmacologic Therapy for Allergic Rhinitis in Children & Adolescents, Age 6 months-17 years, cont’d

Avail- 30-day Generic Name Brand Name Initial Dose ability Generic Brand Ocular Antihistamines, continued azelastine Optivar ≥ 3 yrs: 1 drop affected eye(s) up Rx $19 $158 solution to 2x/day max 8 weeks olopatadine hydrochloride 0.2% ≥ 3 yrs: 1 drop into affected eye Pataday Rx n/a $130 solution once daily olopatadine hydrochloride 0.1% ≥ 3 yrs: 1-2 drops in affected solution Patanol eye(s) 2x/day at interval of 6-8 Rx n/a $145 hrs for up to 6 weeks a Typically sedating however may cause paradoxical excitation in children

Table 7. Pharmacologic Therapy for Allergic Rhinitis in Adults age 18 and Above

Avail- 30-day Generic Name Brand Name Initial Dose ability Generic Brand Intranasal Corticosteroids fluticasone propionate 1 spray each nostril (EN) 2x/day Flonase OTC n/a $26 spray or 2 sprays EN 1x/day flunisolide Nasarel 2 sprays EN 2x/day Rx $32 $66 spray triamcinolone acetonide Nasacort AQ 2 sprays EN 1x/day Rx $40 $123 spray fluticasone furoate 1 spray each nostril (EN) 2x/day Veramyst Rx n/a $120 spray or 2 sprays EN 1x/day beclomethasone dipropionate Qnasl 2 sprays EN 1x/day Rx n/a $126 mometasone Nasonex AQ 2 sprays EN 1x/day Rx n/a $133 spray budesonide Rhinocort 1 spray EN 1x/day (max. 4 Rx n/a $137 spray Aqua sprays/day) beclomethasone dipropionate Beconase AQ 1-2 sprays EN 2x/day Rx n/a $176 spray Oral Antihistamine (2nd Generation) cetirizine Zyrtec 10mg once daily OTC $10 $20 loratadine Claritin 10mg once daily OTC $10 $21 fexofenadine and pseudoephedrine 1 tab (60-120mg) every 12 h $16 $20 Allegra D-12 OTC Allegra D-24 1 tab (180-240mg) every 24 h $13 $50 loratadine and pseudoephedrine Claritin D-12 1 tab (5-120mg) every 12 h $13-25 $22 OTC Claritin D-24 1 tab (10-240mg) every 24 h $45 n/a levocetirizine Xyzal 5mg once daily in the evening Rx $22 $92 cetirizine and pseudoephedrine Zyrtec D-12 1 tab (5-120mg) every 12 h OTC $25 $25 fexofenadine 60 mg twice daily or 180mg once Allegra OTC $33 $77 daily desloratadine Clarinex 5mg once daily Rx $50 $136 desloratadine and pseudoephedrine Clarinex D-12 1 tab (2.5-120mg) every 12 h n/a $112 Rx Clarinex D-24 1 tab (5-240mg) every 24 h n/a $170 * Pricing information for brand products based on average wholesale price (AWP) – 10% found in the RedBook 1/2013 catalog. Pricing information for generic products is based on the Blue Cross Blue Shield Maximum Allowable Cost (MAC) price + $3 as posted on 1/2013. Pricing for OTC products is based on http://www.drugstore.com/ EN=each nostril

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Table 7. Pharmacologic Therapy for Allergic Rhinitis in Adults age 18 and Above, cont’d

Avail- 30-day Generic Name Brand Name Initial Dose ability Generic Brand Oral Antihistamine (1st Generation) chlorpheniramine b 4mg every 4-6 h or 12mg ER Chlor- OTC $10 $15 Trimeton 2x/day (max. 24mg/day) b Benedryl, 25-50mg every 6-8 h OTC $10 $15 various brands clemastine Tavist Allergy 1.34mg 2x/day OTC $11 $15 Oral Decongestants 60 mg every 4-6 h pseudoephedrine Sudafed 120mg ER every 12h OTC $13 $20 240mg ER once daily Leukotriene Inhibitors montelukast sodium Singulair 10mg HS Rx $22 $170 Intranasal Antihistamine azelastine hydrochloride 1-2 sprays EN 2x/day Rx $95 $145 spray Astelin olopatadine hydrochloride 2 sprays in each nostril 2x/day Rx n/a $167 spray Patanase Intranasal Mast Cell Stabilizers cromolyn sodium Nasalcrom 1 spray EN 3-6x/day OTC $15 $30 spray Intranasal Anticholinergic ipratropium bromide Atrovent 0.03% 2 sprays EN 2-3x/day Rx $32 $90 spray Atrovent 0.06% 2 sprays EN 4x/day (max. 3 weeks) Rx $55 $161 Ocular Antihistamines ketotifen fumarate Zaditor, solution Alaway, 1 drop into affected eye every 8- OTC $11 $$13-15 Claritin Eye, 12 h (max. 8 weeks) Zyrtec Itchy Eye azelastine 1 drop into affected eye 2x/day Rx $19 $158 solution Optivar (max. 8 weeks) olopatadine hydrochloride 0.2% 1 drop into affected eye once Rx n/a $130 solution Pataday daily olopatadine hydrochloride 0.1% 1-2 drops into affected eye 2x/day Rx n/a $145 solution Patanol at 6-8 h interval (max. 6 weeks) Ocular Mast Cell Stabilizers cromolyn sodium 4% 1-2 drops into affected eye 4- Rx $33 solution Opticrom 6x/day tromethamine 1-2 drops into affected eye 4x/day Rx n/a $126 solution Alomide sodium 2% 1-2 drops into affected eye 2x/day Rx n/a $128 solution Alocril b Typically sedating medications * Pricing information for brand products based on average wholesale price (AWP) – 10% found in the RedBook 1/2013 catalog. Pricing information for generic products is based on the Blue Cross Blue Shield Maximum Allowable Cost (MAC) price + $3 as posted on 1/2013. Pricing for OTC products is based on http://www.drugstore.com/ EN=each nostril

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Table 8. Common or Serious Side Effects Associated with Medical Therapy for Allergic Rhinitis

Oral Antihistamines (1st generation) Intranasal Products (corticosteroids, Leukotriene Inhibitors Anticholinergic effects antihistamines, mast cell General • blurred vision stabilizers): • • dry mouth Nasopharyngeal • (uncommon) • • nasal irritation • dream abnormalities Central • epistaxis • gastritis, dyspepsia • drowsiness (increased accidents) • , coughing • dental pain • cognitive impairment (any age) • septal perforation • Gastrointestinal Sensory • constipation • smell: reduced of smell Ocular Preparations • GI upset • : unpleasant taste, loss of taste • headache • nausea • global: headache with intranasal • ophthalmic irritation: burning, Sensory steroids dryness, pruritus, stinging • taste: bitter taste, loss of taste • possible contact lens irritation (consult with eye care provider) nd Oral Decongestants Oral Antihistamines (2 generation) General General (rare) • dizziness • GI upset • headache • headache • nervousness • drowsiness (1-3%) • tachycardia • myalgias • insomnia • palpitations • weakness • urinary retention

Table 9. Possible Indications for Referral to Specialist

• Identify specific allergens for patients • Need for improved allergen avoidance education • Intolerance to, contraindication of, or failure of medical • Moderate to severe symptoms of seasonal or perennial management (See Table 9) rhinitis • Symptoms interfere with daily activities, or sleep • Any severe allergic reaction that causes patient or parental anxiety • Associated comorbidities such as chronic or recurrent bacterial rhinosinusitis, or recurrent , nasal polyps, asthma, • Immunotherapy is a consideration (See also: Table 4) atopic dermatitis, ocular symptoms, sleep apnea • Persistent nasal obstruction despite medical therapy

Clinical Background productivity losses due to drowsiness and cognitive/motor impairment from sedating antihistamines are estimated to 6.7 billion dollars annually (adjusted to 2013 dollars). Clinical Problem and Management Issues Untreated allergic rhinitis can lead to multiple complications Incidence. Allergic rhinitis, the most common form of as outlined on Table 1. These include progression to and rhinitis, affects 20-40 million people in the United States exacerbations of asthma, deviations in facial growth, nasal annually, including 10-30% of adults and up to 40% of polyps, and recurrent sinusitis. children. Although the disease tends to be more prevalent among males during childhood, the gender ratio among Diagnosis. Allergic rhinitis is primarily diagnosed on the adults is approximately equal. basis of history, with physical examination providing additional clues. Because of the significant overlap of its The severity of allergic rhinitis ranges from mild to seriously symptoms with those of other nasal conditions, diagnosis debilitating; its social and financial impact is significant. may not be straightforward. Allergy testing may help in the Allergic rhinitis accounts for 4.5 billion dollars annually in diagnosis but must be properly performed in order to avoid direct costs with prescription medications accounting more false negative results. than for half of this cost. Indirect costs from work

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Testing/referral. When history is not adequate for History Assessment of a patient who presents with diagnosis, skin or RAST () testing is symptoms of allergic rhinitis begins with a detailed history helpful to (a) differentiate allergic from non-allergic rhinitis regarding the pattern, frequency, duration, severity, and symptoms and (b) to identify specific allergens that may seasonality of symptoms (or lack thereof), response to cause symptoms. Skin tests are more sensitive, faster, and medications, presence of coexisting conditions (especially more cost-effective than RAST. However, skin testing needs atopic conditions, eczema, and asthma), occupational to be performed by a physician trained in using a well- exposure, environmental history, and identification of controlled process and in interpreting results relevant to the precipitating factors. Family history of atopic disease is often patient. positive in patients with allergic rhinitis. An integral part of the assessment is an evaluation of the degree to which Treatment. Treatment options for allergic rhinitis include symptoms affect the patient’s quality of life, physical and environmental control (allergen avoidance), social functioning, mental health, energy level, sleep, and pharmacotherapy, and immunotherapy (“allergy shots”). general health perception. Response to previous medication Most treatment regimens employ one or a combination of trials should be assessed. these options. While each option has been shown to be effective in treating allergic rhinitis, they have significant Physical examination. Examine the mouth, eyes, ears, costs as well. Medications and changes in the home nose, and lungs: environment can result in sizable direct expenditures, while Mouth: breathing, shape of jaw (i.e. elongated maxilla for immunotherapy necessitates frequent office visits, often over adenoidal facies, narrow arched palate, dental a number of years. malocclusion, overbite, crossbite, presence and size of , cobblestoning of the posterior nasal , secretions (post nasal drip). Rationale for Recommendations Eyes: presence of allergic shiners and Dennie’s lines (infraorbital discoloration and lines caused lower lid Definition ), conjunctival erythema, or cobblestoning, corkscrewing of scleral vessels. Allergic rhinitis is an IgE-antigen and mast cell mediated Ears: look for effusion. inflammation of the membranes lining the nose. The disease is characterized by sneezing, congestion, clear Nose: presence of nasal crease (allergic salute in children) rhinorrhea, and nasal or palatal itching. The disease may congestion, turbinate size, color (pale or bluish is more also coexist with (characterized by likely to be allergic, atrophic may be very pale, itchy, watery eyes that may also be red or swollen). is typically red), physical obstruction i.e. polyps, nasal Allergic rhinitis may be seasonal, perennial, or may occur septal deviation, presence and color of mucus (clear-white sporadically after specific exposures. is usually allergy, green/yellow suggests infection. Having the patient sniff may demonstrate internal valve collapse. Epidemiology Testing Allergic rhinitis manifests in two forms. Seasonal allergic rhinitis tends to be associated with cyclical changes in the Testing is not indicated in mild, easy to control allergic environment. In contrast, perennial allergic rhinitis does not rhinitis patients. For more severe patients, skin tests and exhibit a seasonal pattern; this may reflect the patient’s RAST (radioallergosorbent test) identify the presence of IgE continuous exposure to the offending allergen (e.g., animal, to a particular allergen. Testing is helpful to: house dust , occupational exposures). • Differentiate allergic from non-allergic rhinitis symptoms • Identify specific allergens where avoidance may help Distinguishing prevalence rates of seasonal versus perennial • Identify allergens for immunotherapy. allergic rhinitis is complicated by two factors: first, epidemiologic studies have focused primarily on seasonal Skin tests are more sensitive, faster, and more cost-effective allergic rhinitis (e.g., fever), and second, the symptom than RAST testing. Antihistamines should be stopped 7-10 complex of perennial allergic rhinitis overlaps with those of days before skin testing, but do not need to be stopped prior seasonal allergic rhinitis, chronic sinusitis, recurrent upper to RAST serum tests. Intranasal corticosteroids, leukotriene respiratory infections, and vasomotor rhinitis. inhibitors, decongestants, oral corticosteroids do not need to be stopped for skin testing. Patients who cannot stop their Diagnosis antihistamines because of symptoms should keep their appointment with the allergist. Common symptoms and signs suggestive of allergic rhinitis are summarized in Table 2. More detailed information about Skin testing should be performed by a physician trained in relevant aspects of the history and physical examination are allergy testing and interpretation. Effective testing requires presented below. Common alternative diagnoses are a well-controlled process with consistent application summarized in Table 3. technique and proper precautions for patients who react to

10 UMHS Allergic Rhinitis Guideline October 2013 skin testing (approximately 1-10% of patients). Proper heating system, and use of humidifiers and air conditioning. technique is vital to producing accurate and reproducible Indoor mold can be controlled somewhat via chemical and results. Interpreting skin or in-vitro tests for a specific IgE physical measures such as fungicides, careful cleaning of requires knowledge of locally-present , their humidifiers and vaporizers, and placement of a plastic vapor clinical importance, and their cross-reactivity with barrier over exposed soil in crawl spaces. Dehumidifiers in botanically-related species. The number of skin tests needed basements and other damp areas may help reduce mold may vary with the patient’s age, potential allergen exposures, levels. The overall effectiveness of these measures, and geographic region. however, is condensation levels.

Treatment House dust mites. Fecal residue from dust mites is the primary allergen in household dust. The dust mites’ Figure 1 presents an overview of considerations and steps in principle food source is exfoliated ; as such, mite treating allergic rhinitis. Table 4 summarizes advantages of concentrations are highest in bedding, fabric-covered the major treatment options. Of these allergy testing (skin furniture, soft toys, and carpeting. While no effective means testing, RAST testing) was discussed immediately above and currently exist in the US for permanently eliminating mites environmental control/avoidance of options, medications, from upholstered furniture and carpeting, physical and and subcutaneous immunotherapy are discussed below. chemical barriers offer some relief. Physical barriers may include allergen-proof encasings for mattresses, pillows, box Treatment by avoidance or environmental control. springs, and bedding; using plastic, wood, or leather Avoidance of inciting factors (e.g., allergens, irritants, furniture in lieu of upholstered furniture, and replacing medications) is fundamental to the management of allergic carpeting with wood or vinyl flooring. Homes should be rhinitis. dusted and vacuumed frequently and bedding should be washed in hot on a weekly basis. It is best to eliminate Triggers for allergic rhinitis may be grouped into five major stuffed animals from the affected child’s room. categories: , molds, house dust mites, animals, and insect allergens (e.g., cockroaches, bee venom). Exposure to Chemical treatments include using 3% tannic acid solution tobacco smoke can also increase symptoms of allergic (e.g., Allersearch® ADS Anti-Allergen Dust Spray) to rhinitis, so this exposure should be eliminated or minimized. denature dust mites in upholstered furniture and treating The effectiveness of control measures instituted is assessed carpeting with a compound containing benzyl benzoate (e.g., primarily by patient symptoms and the necessity of Arcarosan). The effectiveness of chemical treatments medications. depends upon their repeated application. Lowering indoor humidity to less than 50% is recommended. Pollens. -triggering allergic rhinitis is principally derived from wind-pollinated trees, grasses, and weeds. In Regarding indoor air, lowering humidity to less than 50% is Michigan, (and the northern United States in general), the recommended. Evidence regarding the effect of air purifiers predominant sources of pollen vary with the season: on alleviating symptoms is either • April – May = tree pollen nonexistent (for electrostatic purifiers) or conflicting (for • May – June – early summer = grass pollen HEPA air purifiers). Similarly, cleaning heating ducts is of • August – September = weed pollen no demonstrated value. • September – October = seasonal mold Animal allergens. All warm-blooded animals, including Reducing pollen exposure is important to the effective birds, are capable of sensitizing a susceptible allergic patient. management of allergic rhinitis; this can be accomplished by While exposures to mice, rats, guinea pigs, and farm animals closing doors and windows, using air conditioning on an constitute occupational hazards for some, the most common indoor cycle, minimizing the use of window or attic fans, and manifestations of animal allergy are to cats and dogs. Cat and limiting outdoor activity. Showering or bathing after dog allergens are notable for the ease and extent of their outdoor activity removes pollen from the hair and skin and dissemination, particularly through passive means (i.e., helps avoid contamination of bedding. Nasal rinses transport on clothing). Removing the offending animal from can be used after being outdoors to help minimize exposure. the household is preferred. Because significant cleaning In highly sensitive patients, effective allergen avoidance may measures are required to reduce cat and dog allergen levels require severely curtailing the patient’s outdoor activity. to those found in environments not inhabited by cats or dogs, if the animal is still present, the effectiveness of cleaning is Molds. Molds proliferate in both indoor and outdoor limited. Cleaning may include washing the animal itself on environments. Most mold allergens are encountered through a weekly basis. Evidence in support of this practice is mixed, inhalation of mold spores. Patients can avoid outdoor molds but washing should never be attempted by the allergic by remaining indoors and using air conditioning on an indoor patient. If the allergenic animal is not to be removed from cycle; however, it is important to note that air conditioning the home, confining it to an uncarpeted room with an units themselves may be heavily contaminated with mold. electrostatic or HEPA air purifier may markedly reduce Indoor mold is influenced by the age and construction of the airborne allergens in the rest of the home. Reduce exposure building, presence of basement or crawl space, type of by keeping the animal out of the patient’s bedroom. Families 11 UMHS Allergic Rhinitis Guideline October 2013 can also consider an Allerca cat, which is hypoallergenic, but ineffective medications. If a patient is not well-managed with more studies need to be done on these animals. (Although non-sedating antihistamine alone and an intranasal is some dog breeds are said to be hypoallergenic, this has not added, the antihistamine may possibly be stopped after good been demonstrated.) symptom control is achieved. Additionally, some patients may be able to reduce or stop therapy seasonally when their Insect allergens. Sources of insect allergens include symptoms are absent or less severe. cockroaches, crickets, flies, midges, Asian ladybugs, and moths. Debris from these insects is associated with allergic Intranasal corticosteroids. A number of studies have rhinoconjunctivitis and asthma. The most common of these, shown these to be the most effective treatment of the the cockroach allergen, is found on the insect’s body and in itching, sneezing, rhinorrhea, and stuffiness associated with its feces. While careful sanitation practices are often allergic rhinitis. Their effect is not immediate, however. effective in reducing or eliminating cockroaches, heavy Onset of relief is seen on day 2 to 3 with effects reaching infestation may require application of pesticides by a their peak at 2 to 3 weeks. Regular, consistent use is required professional exterminator. To prevent insects entering the to maintain a maximum effect. Patient education for the home, make sure that windows and walls are tightly sealed. correct use of intranasal pump sprays is essential. Some Pyrethroid chemical can also be applied to the outside of the evidence indicates that intranasal corticosteroids improve home prior to the start of cold weather. ocular symptoms.

Tobacco smoke. Exposure to tobacco smoke should be Intranasal corticosteroids are well tolerated and have a eliminated or minimized, since it can increase allergic relatively good safety profile. Newer, more potent symptoms. Individuals (e.g., family members) who formulations offer the advantages of once daily dosing, frequently smoke around an allergic patient should be minimal to no systemic absorption, and demonstrated encouraged to quit (see UMHS Tobacco Use Cessation tolerability in pediatric patients. The incidence of adverse guideline) or smoke outside the home. Allergic patients effects is between 5-10%. Local effects most commonly should avoid environments with tobacco smoke. reported include sneezing, stinging, and burning or irritation. However, these effects are generally mild and do not Pharmacological therapy. Several classes of drugs preclude the use of intranasal preparations. Aqueous comprise the mainstay of treatment of allergic rhinitis; of formulations are preferred because they are less irritating to these, the primary ones are intranasal corticosteroids and oral the nasal mucosa. A deviated septum may obstruct the antihistamines. Table 5 summarizes the order of medication distribution of medicated nasal sprays and reduce their addition based on presenting symptoms. Tables 6 and 7 potential effectiveness. summarize information on specific drugs, their dosing, and costs for pediatric and for adult populations, respectively. Oral antihistamines. Antihistamines are effective in Table 8 summarizes common and serious side effects reducing symptoms of itching, sneezing, and rhinorrhea and associated with medical therapy for allergic rhinitis. In should be tried with most patients as first-line therapy for addition to safety and effectiveness, ongoing cost of allergic rhinitis. Oral antihistamines also reduce symptoms medication should also be considered. Before considering of allergic conjunctivitis, which are often associated with each class of drugs individually, a broader context for cost- allergic rhinitis. While they tend to be less efficacious effective prescribing is summarized. overall compared to the intranasal steroids, antihistamines appear to be equally effective in blocking - Cost-effective prescribing. Treatment choices for mediated responses to allergens. individual patients are driven by several factors beyond safety and effectiveness. Because of the over-the-counter All antihistamines appear to be equally effective; however, availability of many oral and topical agents, a history of a first generation agents adversely affect cognition and patient’s attempts at self-care should be obtained. Cost of performance. It is therefore recommended that therapy be therapy can vary widely, depending on drugs chosen and initiated with generic loratadine or fexofenadine. Some whether the patient has drug coverage or not. Generic drug patients may get better symptom relief with cetirizine. For products should be used whenever possible to reduce patients that cannot afford OTC loratadine, fexofenadine, or medication costs. Most prescription drug plans cover certain cetirizine, chlorpheniramine is inexpensive and effective. It agents preferentially at a lower copay than others. While they is the least sedating of the 1st generation antihistamines; often do not cover nonprescription products, patients can however, it must still be used with caution in patients submit receipts for over-the-counter allergy products for requiring mental alertness. reimbursement through flexible spending accounts. Decongestants. Decongestants act on Using lowest effective doses and minimizing medications receptors to produce and decrease swelling can also reduce medication costs. This can be accomplished of the nasal mucosa which, in turn, alleviates nasal by stepdown therapy after a patient has been well-controlled. congestion. Oral decongestants may be used until symptoms Symptom control may be possible a lower dose of resolve. Oral decongestants (including combination medications than needed to gain control. Patients and products containing a decongestant—see below) should be providers should be vigilant in stopping unneeded or used with caution in patients with hypertension, ischemic

12 UMHS Allergic Rhinitis Guideline October 2013 heart disease, glaucoma, prostatic hypertrophy, or diabetes treatment of seasonal allergic rhinitis, intranasal mellitus. Oral decongestants are contraindicated in patients antihistamines offer no therapeutic benefit over conventional using monoamine oxidase inhibitors (MAOIs) or having treatment. More recent evidence suggests that combination uncontrolled hypertension or severe coronary artery disease. of intranasal antihistamines and intranasal corticosteroids are In addition, geriatric patients may be more sensitive to the synergistic and provide greater benefit than monotherapy in side effects of oral decongestants. Topical decongestants do the treatment of seasonal allergic rhinitis. not exhibit significant systemic absorption in usual doses, but due to the risk of rebound (rhinitis Ocular Medications. Ocular medications for allergic medicamentosa) or atrophic rhinitis with chronic use, these conjunctivitis are available as topical solutions or agents have no role in the maintenance treatment of allergic suspensions. They contain antihistamines or mast cell rhinitis. They may be used short-term (3-5 days) for the stabilizers. Side effects of ocular medications are generally severely congested patient to improve initial drug delivery mild and include a brief stinging, burning sensation. Ocular with intranasal corticosteroids. antihistamines can be used as needed for symptomatic relief and prophylaxis of allergic symptoms with minimal Combination antihistamine/decongestant. Patients for systemic side effects. whom an antihistamine or decongestant alone fails to provide complete relief may benefit from an antihistamine/ Sodium cromolyn has been shown to be effective for the decongestant combination. Studies have shown improved treatment of seasonal allergic conjunctivitis and should be allergy symptom control when a decongestant has been administered on a regular basis. Lodoxamide has been shown added to antihistamine therapy. Decongestant-containing to be as effective as or more effective than sodium cromolyn products are approved only for patients 12 years of age and in vernal (spring) conjunctivitis. Soft contact lens users and older; however, pseudoephedrine can be added as a separate patients with sensitivities to certain preservatives should agent in children as young as 2 years of age. The cautions consult their eye care provider or refer to specific product enumerated above for decongestant use also apply to information regarding the use of these products. Intraocular combination products. corticosteroids are best left for ophthalmologists to prescribe.

Leukotriene inhibitors. Leukotriene inhibitors reduce Nasal saline. Saline sprays theoretically moisten the allergy symptoms through inhibition of inflammation and and promote mucociliary clearance. Saline also have proven efficacy for control of asthma. Several solutions also contain magnesium, which possibly reduces large studies have evaluated montelukast and have shown a inflammation in the nasal mucosa. Note that saline irrigation reduction in itching, sneezing, rhinorrhea, and congestion. solutions should be prepared with purified water, not tap Efficacy appears comparable to oral antihistamines but water.) multiple studies demonstrate that inhaled corticosteroids have superior improvement in nasal obstructive symptoms One small comparative study showed that intranasal compared to leukotriene inhibitors. Combination therapy of hypertonic saline spray improved symptoms of allergic leukotriene inhibitors and antihistamines improved rhinitis, but saline was not as effective as intranasal intranasal symptom compared to monotherapy, but were corticosteroids. Therefore, saline solution can be an again less effective when compared to inhaled nasal steroids effective adjunctive medication for mild-to-moderate alone. Leukotriene inhibitors may have a role as second line allergic rhinitis. therapy in patients with comorbid persistent asthma to control both and reduce medication costs. A Cochrane database study evaluated the use of nasal irrigations for the treatment of chronic rhinosinusitis (CRS). Nasal cromolyn. Nasal cromolyn is reserved for patients The evidence suggests that saline irrigations provide benefit who are not well-controlled or do not tolerate oral in the treatment of chronic rhinosinusitis as monotherapy or antihistamines or intranasal steroids. It is most effective as an adjunct to other therapies. Because a significant when used regularly prior to the onset of allergic symptoms. number of patients with CRS have coexistent allergic The four times daily dosing can cause compliance problems. rhinitis, the addition of saline irrigations may provide benefit and be adjunctive to other treatments such as intranasal Anticholinergics. Ipratropium bromide (Atrovent) is an corticosteroids and antihistamines. effective anticholinergic spray for patients with severe vasomotor symptoms (profuse thin rhinorrhea). Immunotherapy. Allergen immunotherapy is the repeated Anticholinergics decrease the production of mucus and administration of specific allergens to patients with IgE diminish rhinorrhea. mediated conditions for the purpose of desensitizing them to the offending allergens. It is the only disease remitting agent Nasal Antihistamines. Intranasal antihistamines are available. Well controlled clinical trials have demonstrated effective in treating the nasal symptoms associated with its effectiveness for seasonal and perennial allergic rhinitis, seasonal and perennial rhinitis and nonallergic vasomotor seasonal asthma, ocular allergy, and in patients with eczema rhinitis. When administered intranasally, the primary and positive skin tests. It may prevent polysensitization to adverse effects are nasal burning and altered taste (i.e. bitter other allergens in children and prevent the development of or metallic taste). While effective in the symptomatic asthma. No long term negative effects have been reported.

13 UMHS Allergic Rhinitis Guideline October 2013

Referral/Consultation Sublingual immunotherapy (drops, tablets applied orally) is a new modality, is less efficacious then subcutaneous, is Appropriate criteria for referral to a colleague who currently not approved for use by the FDA, but is available specializes in the diagnosis and treatment of are in Europe. summarized in Table 9. Criteria for referral include identification of specific allergens, intolerance to or failure (Xolair). A recombinant DNA derived IgG1 of medical therapy, severe reactions, associated comorbid monoclonal antibody that selectively binds to circulating IgE conditions, or desire for allergen immunotherapy. and limits the amount of IgE available to bind to FCR1 receptors on mast cells. This limits the release of mediators and modifies the allergic response. It decreases the number Special Considerations of FCR1 receptors on . Studies in patients with allergic rhinitis have shown a decrease in mediators released, Pediatrics decrease in symptoms and need for rescue medication, and improved quality of life scores. Long term effects are not For children with occasional symptoms, antihistamines can known. The drug is expensive and is currently not approved be taken on days when symptoms are present or expected. for use in patients with allergic rhinitis. Children experiencing daily symptoms achieve the most relief when taking antihistamines continuously throughout Surgical therapy. For patients who have persistent nasal the pollen season. Second-generation, less-sedating, obstruction after adequate trial of medical therapy (with or antihistamines should be used for school-age children. without immunotherapy), referral to a surgical specialist Intranasal corticosteroids, especially fluticasone and should be considered for possible reduction of the inferior mometasone have demonstrated an excellent safety profile in turbinates, which has been demonstrated to lead to objective children with minimal systemic absorption and no evidence and subjective improvements in airflow symptoms. of growth retardation. Occasionally, a septoplasty is necessary to allow for proper steroid and other medicated nasal sprays to pass beyond a Consider referring children with moderate to severe allergic severe septal deviation. Other sites of obstruction should also rhinitis to an allergist for evaluation for possible be considered. Internal nasal valve collapse may also be immunotherapy. Treatment may alter progression of allergic important sites of anatomic obstruction. disease and development of asthma in addition to reducing frequency and severity of flares in patient with comorbid Follow Up asthma.

Short term reevaluation should be done to assess response to Geriatrics a change in therapy or to review symptoms during seasonal worsening. An accurate diagnosis of allergic rhinitis in the elderly can be difficult because many factors may cause chronic rhinitis Periodic assessment of patients should be performed every symptoms (see Table 2). In this population alternate six months to a year, depending on severity and treatment. diagnoses include non-allergic or atrophic rhinitis, Assess for symptom control and for complications and side Medication side effects (particularly from antihypertensive effects of treatment. medications such as ACE inhibitors and beta blockers), include autonomic dysfunction, gustatory rhinitis, and acute angle glaucoma.

Older adults with allergic rhinitis can present special treatment challenges. In particular, medication safety can be problematic, owing to increased pharmacodynamic sensitivity to sedating side effects of antihistamines, or presence of contraindicating or precautionary conditions (e.g., cardiac disease, prostatic hypertrophy) from use of some medications. While topical medications have a better safety profile in general, difficulties with manual dexterity can impair ability to use nasal and ophthalmic products.

Pregnancy

Allergic rhinitis does not follow a predictable pattern during pregnancy; it may worsen, improve, or stay the same. Hormonal changes associated with pregnancy may exacerbate symptoms. Rising progesterone and estrogen levels may increase glandular secretions and vasodilation, 14 UMHS Allergic Rhinitis Guideline October 2013 and increased blood volume may cause nasal vascular pooling. In contrast, increased serum free cortisol during Testing pregnancy could improve symptoms. Cytotoxicity testing, provocative and neutralization testing Medications should be prescribed during pregnancy when carried out by either intracutaneous or subcutaneous the apparent benefit of the drug outweighs the apparent risk. injection or sublingual administration, and measurement of Agents used to treat allergic rhinitis in pregnancy should be specific and non-specific IgG4 have not been validated by either category B (presumed safe based on animal studies, accepted standards of scientific evaluation and as such are but without adequate data in humans), or category C (of considered unproven, controversial, and inappropriate for uncertain safety, with no demonstrated adverse effects in diagnostic use. animals or humans). If possible, medication should be avoided in the first trimester because of the potential risk of Treatment, Cost, Strategy congenital malformations. In general, it is considered safe to continue immunotherapy during pregnancy. Pharmacologic control of allergic rhinitis is expensive for ongoing treatment. For mild to moderate nasal symptoms of allergic rhinitis, nasal saline irrigation should be recommended as first line Immunotherapy (allergy shots) may provide significant long- therapy given its proven safety and efficacy. For more severe term control of symptoms at a reduced cost and without the or persistent symptoms, intranasal budesonide (category B) risks of medication, but requires multiple office visits, which can be prescribed; all other intranasal corticosteroids are compromises patient compliance. These issues must be rated category C. A study showed no increased risk of weighed when considering treatment options. adverse fetal outcomes with maternal exposure to inhaled budesonide, and intranasal budesonide should be at least as For children with allergic rhinitis and comorbid asthma, safe because of the lower systemic exposure. Providers immunotherapy is cost beneficial. could also choose intranasal cromolyn (category B) but this is not as effective as intranasal corticosteroids. Strategy for Literature Search If prescribing an oral antihistamine, providers should choose either: The literature search for this update began with the results of • first-generation antihistamine chlorpheniramine the literature searches performed for the 2002 and 2007 (category B) or versions of this guideline. Also referenced was the search • second-generation agents, loratadine or cetirizine (both performed for Allergic Rhinitis and its Impact on Asthma category B). (ARIA) 2010 revision. Geneva: World Health Organization (WHO), which included literature through Aug. 2007. A Severe Asthmatics search for literature published since that time was performed. The search on Medline was conducted prospectively for Rhinosinusitis can exacerbate asthma. Desensitization can literature published from 8/1/07 to 3/30/12 using the major improve asthma control for those patients with allergic keywords of: allergic rhinitis, human (adult and pediatric), asthma. Consider referral if rhinitis or asthma is poorly English language, clinical guidelines, controlled trials and controlled. meta analyses, and cohort studies. Separate searches were performed for: history ((inciting factors, seasonality, family Severe Atopic Dermatitis Patients history, severity & severity scoring), physical exam, signs, symptoms (nasal exam for changes in mucosa, conjunctival Patients with atopic dermatitis tend to be severely allergic changes), laboratory (nasal smear for presence of and should be referred if initial therapy is unsuccessful. eosinophyls, skin testing; RAST), Diagnosis – other references, control triggers, corticosteroids (intra-nasal, ocular), antihistamines (intra-nasal, oral, ocular), Complementary and Alternative Medicine leukotriene inhibitors/modulators, decongestants (intra- nasal, ocular, oral), mast cell stabilizers (intra-nasal, Complementary and alternative medicine (CAM) is widely ocular), non-steroidal anti-inflammatory (ocular), practiced by patients to treat allergic rhinitis. Many patients anticholinergics (intra-nasal), omalizumab, saline irrigation that use CAM report improvement in symptoms. However, to remove allergens (, eye wash), no evidence definitively supports the efficacy of CAM in the immunotherapy/allergy shots or , turbinate reduction treatment of allergic rhinitis. In addition, CAM may have surgery, integrative/ alternative/ complementary medicine, side effects and some of the medications used may interact pregnancy & lactation), treatment or management – other with other drugs. Some studies have shown some decrease references, geriatric patients, cost and cost-effectiveness, in symptoms with and probiotics; however other references. medication therapy has not been able to be decreased. More studies need to be done in this area. The search was conducted in components each keyed to a Controversial Areas specific causal link in a formal problem structure (available 15 UMHS Allergic Rhinitis Guideline October 2013 upon request). The search was supplemented with recent Review and Endorsement clinical trials known to expert members of the panel. Negative trials were specifically sought. The search was a Drafts of this guideline were reviewed in clinical conferences single cycle. Conclusions were based on prospective and by distribution for comment within departments and randomized clinical trials if available, to the exclusion of divisions of the University of Michigan Medical School to other data; if RCTs were not available, observational studies which the content is most relevant: Allergy, Family were admitted to consideration. If no such data were Medicine, General Internal Medicine, General Pediatrics, available for a given link in the problem formulation, expert and Otolaryngology. The guideline was approved by the UM opinion was used to estimate effect size. C. M. Mott Children Hospital’s Pediatric Medical Surgical Practice Committee and Executive Committee. The final version was endorsed by the Clinical Practice Related National Guidelines Committee of the University of Michigan Faculty Group Practice and the Executive Committee for Clinical Affairs of The UMHS Clinical Guideline on Allergic Rhinitis is the University of Michigan Hospitals and Health Centers. consistent with: Allergic Rhinitis and its Impact on Asthma (ARIA) 2010 revision. Geneva: World Health Organization (WHO). Acknowledgments

The Diagnosis and Management of Rhinitis: An Updated The following individuals are acknowledged for their Practice Parameter, AAAAI, 2008 contributions to previous versions of this guideline.

2002: Richard Orlandi, MD, Otolaryngology; James Measures of Clinical Performance Baker, MD, Allergy; Margie Andreae, MD, Pediatrics; Daniel Dubay, MD, General Medicine; Steve Erickson, At this time no major national programs have clinical PharmD, Pharmacy. performance measures specifically for the diagnosis and treatment of otitis media. 2007: David A. DeGuzman, MD, General Medicine; Catherine M. Bettcher, MD, Family Medicine, R. Van Disclosures Harrison, PhD, Medical Education; Christine L. Holland, MD, Allergy ; Cary E. Johnson, PharmD, Pharmacy, Sharon The University of Michigan Health System endorses the Kileny, MD, Pediatrics; Jeffrey E. Terrell, MD, Guidelines of the Association of American Medical Colleges Otolaryngology. and the Standards of the Accreditation Council for Continuing Medical Education that the individuals who present educational activities disclose significant Annotated References relationships with commercial companies whose products or services are discussed. Disclosure of a relationship is not Allergic Rhinitis and its Impact on Asthma (ARIA) 2010 intended to suggest bias in the information presented, but is revision. Geneva: World Health Organization (WHO); made to provide readers with information that might be of 2010. [available at www.whiar.org/docs/ARIAReport_2010.pdf]. potential importance to their evaluation of the information. Also published as: Brozek JL, Bousquet J, Baena-Cagnani CE, et al. Allergic rhinitis and its impact on asthma (ARIA Team Member Company Relationship guidelines: 2010 revision. Journal of Allergy and Clinical , 2010; 126(3):466-476. Catherine Bettcher, MD (none) Guideline of ARIA. David DeGuzman , MD (none) R Van Harrison, PhD (none) Christine Holland, MD (none) Wallace DV, Dykewicz MS, et al (eds.) The diagnosis and Lauren M. Reed, MD (none) management of rhinosinusitis: An updated practice Tami L. Remington, (none) parameter. Journal of allergy and Clinical Immunology, PharmD 2008; 122:S1-S84. [Available through Mark A. Zacharek, MD Entellus, Teva Consultant http://www.aaaai.org/practice-resources/statements-and- Respiratory practice-parameters/practice-parameter-guidelines.aspx] Guideline of the American Academy of Allergy, Asthma, and Immunology.

Shearer WT, Leung DYM (eds.). 2010 primer on allergic and immunologic diseases. Journal of Allergy and Clinical Immunology, 2010; 125(2):S1-S381. (Available at http://www.jacionline.org/issues?issue_key=S0091- 6749%2810%29X0004-5)

16 UMHS Allergic Rhinitis Guideline October 2013

Special supplemental issue published every 2-3 years and devoted to many aspects of allergic, immunologic, and asthmatic disorders.

Sheikh, A; Hurwitz, B; Shehata, Y.House Dust mite Avoidance Measures for Perennial Allergic Rhinitis, 2007

17 UMHS Allergic Rhinitis Guideline October 2013